By Mark Wolf
Dr. Avani Khatri spent several minutes examining the small mouth of the boy in the dental chair, then pronounced her findings.
“We can probably get away with doing fillings and not crowns,” she said through her mask.
Khatri, a University of Colorado Dentistry School graduate, and dental assistants Nancy Vigil and Taylir Scott-Hall rotate among young patients who occupy each of three dental chairs at the Kids In Need of Dentistry (KIND) clinic at Morey Middle School inDenver.
Every Thursday the clinic treats a steady stream of pediatric patients, many with a mouthful of problems. Mondays through Wednesdays the team sees patients at Tri-County Health Department. Another clinic in Colorado Springs, staffed by volunteers, will lose its current home at the end of May. The clinic accepts Medicaid and parents pay 20 percent of usual fees for the procedures.
“Mostly we see kids with generalized gross decay. We do a lot of hygiene, fillings, crowns, run-of-the-mill general dentistry,” said Khatri.
Colorado below average in dental care
Colorado ranks 38th among the 50 states in the number of children receiving preventive dental visits in the previous year, contributing to a C- grade in the Healthy Children category of the Colorado Health Foundation’s 2011 Colorado Health Report Card. Of 39 categories on the report card, the adolescent dental category was the state’s second-lowest ranking. (Colorado stood 39th in the percentage of babies with low birth weight.)
Colorado ranks 30th nationally in the percentage (70.6) of residents served by water fluoridation. In 2002, the state was 24th with 75.4 percent of the state’s water supply being treated with fluoride.
Untreated dental caries (the disease process that causes cavities) is the leading disease in children, occurring five times more often than asthma. Dental disease causes children and parents to miss millions of hours of school and work. The incidence of cavities in children ages 2-5 has increased nationally in the face of an overall decrease among the general population.
What is both encouraging and frustrating to health officials is that dental disease is considered 100 percent preventable. Oral health has been tabbed as one of Colorado’s 10 winnable health battles and has a role in the governor’s TBD “listening tour.”
Millions spent on surgery
Pediatricians say far too many youngsters have surgery for dental disease that could have been prevented. During 2011 nearly 3,000 children visited the operating room at Children’s Hospital for dental surgery.
“That number has been increasing for every year for the past decade,” said Dr. Patricia Braun, a pediatrician at Denver Health. “It is a large economic issue. Studies have shown that restoring dental disease in an operating room costs about $10,000 to $15,000 per case. If you take 3,000 kids to the OR, that’s $35 (million) to $45 million spent each year restoring a preventable disease.”
Fifty-seven percent of 3-year-olds seen at Denver Health have dental disease and the mean number of cavities is 11.
“If you include white spot lesions that indicate early signs of cavities forming, over 70 percent have dental disease,” said Braun.
Dental disease in children is prevalent across income levels but disproportionately affects low-income children.
“Seventy-five percent of the disease is in 25 percent of low-income kids,” she said.
Health officials believe the twin tools of education and early intervention are keys to reversing the trend of increasing cavities.
“We truly have an achievement gap,” said Dr. Katya Mauritson, a dentist and director of the oral health unit of the Colorado Department of Public Health and Environment. “With millions of school hours missed, how does that translate to lifelong core outcomes for a vulnerable population and how do we change behaviors at an early age?
“We need to look at very young children and make sure they’re getting in for their age-one dental visit so if there is a problem they’re not going to be sent to the OR to have 20 teeth capped at age 4 and they’re not going to suffer the pain of that treatment,” said Mauritson.
The causes of the rise in pediatric cavities are evident, providers say.
“It’s a combination of things. One is dietary factors. The more sugar kids have puts them at a higher risk. It’s a lack of good oral hygiene, brushing teeth. It’s also because it’s a vertically transmitted disease. The bacteria that are associated with causing caries are transmitted from the primary caregiver to the child at about the time the kid’s teeth start to erupt,” said Dr. Mark Deutchman, a professor of family medicine at the University of Colorado School of Medicine.
Deutchman is one of the authors of Smiles For Life, a national oral health curriculum used to train doctors and dentists.
“The mythology is that ‘they’re just baby teeth and it doesn’t really matter,’ but the best predictor of your adult teeth health is your child teeth. Those baby teeth are in your mouth while the adult teeth are coming in. If you have the bacteria and poor oral hygiene habits it’s going to spread to your adult teeth,” he said.
“Children get abscesses, facial infections, pain. They can’t pay attention in school, have to go to the emergency room and parents have to take off work,” Deutchman said.
A grant from Delta Dental Foundation was used to develop the Frontier Center at CU to improve communication between medical and dental professionals. Deutchman teaches oral health education in the medical school and medical condition education in the dental school.
“We have to get more general dentists to take Medicaid and to see young kids, and continue to get more physicians to include dental health as part of their well-child check,” he said.
About 27 percent of Colorado dentists accept Medicaid.
Colorado foundations are providing the financial fluoride for a number of dental health initiatives, including Cavity Free at 3 (CF3), a statewide initiative to raise awareness about dental disease in young children and pregnant women.
CF3’s funders include the Caring for Colorado Foundation, Colorado Health Foundation, Colorado Trust, Rose Community Foundation, Kaiser Permanente Foundation, and Delta Dental of Colorado Foundation.
“We train providers (physicians, physicians assistants and nurses) in the skills to do oral screening, identify disease, do a risk assessment and, when indicated, a fluoride varnish as part of well-child visits,” said Karen Savoie, director of education for CF3.
CF3 has trained more than 1,500 providers throughout Colorado since its founding in 2008.
“We focus on areas of the state with the greatest barriers of access to care: rural areas, where dental services are limited,” said Savoie.
CF3 also focuses on dental issues during pregnancies. Only 39.7 percent of al lColorado women receive dental care immediately prior to or just after pregnancy, according to Colorado’s Risk Assessment and Monitoring System. Among Medicaid-eligible women the number drops to 25.6 percent.
“We train providers that dental care is not only safe but recommended during pregnancy,” said Savoie. “We’re asking primary care providers to endorse that message. It’s been very well received. We want them to ask pregnant women if they’ve had a dental appointment and if they say no to encourage them to have one.”
Pregnant women in Colorado have no Medicaid dental benefits except for certain state-defined “concurrent conditions,” including tumors and emergencies. A 2007 report by State Health Policy Monitor found Colorado to be one of only six states with no regular adult dental benefits under Medicaid.
Colorado Senate Bill 108, sponsored by Sen. Jeanne Nicholson, D-Gilpin County, which has been passed by the Senate Health Committee, would provide preventive periodontal, minor restorative care and extraction for pregnant Medicaid recipients.
“The theory is if we can take care of the mom’s dental needs in pregnancy, we can help delay the transmission of dental disease to the child, which gives the child a healthier foundation, which can in turn reduce the high expenses that can be involved treating a child,” said Molly Pereira, associate executive director of the Colorado Dental Association.
The CF3 foundation funders plan to launch in June a $2.25 million statewide program with the dual mission of getting more dentists to accept Medicaid and to see more young patients.
The Colorado Partnership for Children’s Oral Health “is the result of our collective efforts with Cavity Free at 3,” said Linda Reiner, director of planning and evaluation for Caring For Colorado. “What we learned from that is we still had two big barriers: Cavity Free at 3 teaches dentists they need to get kids into a dental home by age 1, but what we kept hearing all around the state was, ‘That’s great but we don’t have any dentists who will see a kid at age 1 and we don’t have any dentists who will take Medicaid.”
Reiner said Colorado only has about 100 pediatric dentists and they are concentrated in the Front Range.
“In rural areas they’re not part of the solution because they’re just not there,” she said. “People say anecdotally that about 30 percent of pediatric dentists take Medicaid. We started modeling this after Colorado Children’s Healthcare Access Program. When Dr. Steve Poole (a pediatrician and founder of CCHAP) started his project in 2006, about 20 percent of pediatricians took Medicaid, and he now has 95 percent of pediatricians taking Medicaid patients.
“We’d like to see all general and pediatric dentists have Medicaid be at least part of their practice.”
To that end, the partnership will send trainers to dentists’ offices to provide information on how to treat young children following the CF3 protocols as well instruction on how to deal with various Medicaid issues.
The partnership will also offer mini-grants in the $25,000 range to local public health agencies, community resource centers, nonprofits or local government entities in mostly rural areas
Access the big issue
The crux of the problem, she said, “boils down to families who have no access to dental care.”
Twenty-two of Colorado’s counties have designations or are partly designated as geographic Dental Health Professional Shortage areas based on their dentist-to-population ratio, reports the Colorado Rural Health Policy and Advocacy News.
Clinics such as KIND are where the enamel meets the drill for many children who are least likely to be able to afford dental treatment on their own.
“We tend to do a lot of oral hygiene education, not just with kids but with their parents,” said Khatri, while she waited for a local anesthetic to take hold before working on another young patient.
“A lot of parents think, ‘We’ll give them a juice pack because it’s 100 percent juice. But have you looked at the sugar content? Apple juice is one of the most sugary juices on the market. People think, ‘I’m not giving them pop, juice is better for them’ and their logic is right but look at how much sugar is in these boxes. I had a patient’s mom tell me ‘I went home and looked at all the boxes and threw them all away.’ Many people are unaware of the hidden sugar in what we eat and drink.”
“We see kids who come in with their mouths pretty much bombed out with decay but not complaining,” said Julie Collett, KIND’s executive director. “They’ve learned to live with pain. They know their parents are trying to put food on the table or gas in the car. They’re in pain, they’re sitting in school and can’t concentrate, can’t function.”
A few miles away near Denver’s eastern border, KIND’s “Miles for Smiles” mobile dental unit, a 36-foot bus, was parked next to an apartment complex. Inside, Dr. John Quigley and dental assistant Lidia Salazar are speaking in soothing tones to a young patient who is receiving a filling and a crown.
“We do fillings, root canals, cleanings, extractions, everything except for braces,” said Krystal Valdez, coordinator for the mobile unit. “We’ve built a bond of trust here. We’re right in their neighborhood.”
KIND, founded by a group of Denver dentists 100 years ago, also operates Chopper Topper, a school-based sealant program that targets second-graders and will have visited 90 elementary schools in 10 districts by the end of this school year.
The Inner City Health Center, 3800 York St., has about 24,000 visits annually, 7,000 of them from patients who visit the center’s six well-appointed dental treatment areas. Most of the center’s patients are adults; 70 percent have no insurance, a figure that rises to 80 percent among those who seek dental care.
“Dentistry has always been an integral part and parcel of our holistic approach to health care,” said executive director Kraig Burleson. “Our emphasis is on adults because they are the ones who have the most difficulty accessing care. Adults just suffer. They go without.”
Everyone pays something on a sliding fee schedule, but the money doesn’t always cover costs. Economics caused Inner City to close a dental clinic on Denver’s west side.
“We hope to reopen it someday. The population we served over there was significant,” said Burleson.
Patient education key
Patient education is an integral piece of Inner City’s program.
“We have a class (on dental health) and patients are given a $35 credit towards their bill if they attend. It used to be mandatory, but we incentivized it instead. Most people never had the opportunity to come and see what’s really causing their disease,” said Dr. Marilyn Vigil Ketcham, Inner City’s dental director.
Inner City provides both comprehensive care and emergency services to help patients avoid the emergency rooms and urgent clinics where, Ketcham said, “They get a Band-Aid, antibiotics and pain medication at a really high price, but nothing is done definitively about their problem.
A report by the Pew Center on the States estimates more than 830,000 visits to emergency rooms in 2009 were the result of preventable dental conditions, a 16 percent increase from 2006.
“We try to offer services most other public health clinics don’t. We do root canals, crowns, bridges, silver and white fillings. About the only things we don’t do are orthodontics and implants. We do a lot of surgery, take out a lot of teeth, do dentures and partial dentures,” said Ketcham.
When a youngster has a well-child visit at the medical clinic on the other side of Inner City’s facility, he or she gets walked over to dental area.
“We do oral hygiene instruction for moms about the things they need to do for diet over next six months and put fluoride on their child’s teeth,” she said.
Inner City also sees a significant portion of retirees.
“Medicare doesn’t cover dental. A lot of our seniors are on fixed income and this allows them an opportunity for maintenance on their teeth, dentures, partial dentures, getting them rehabbed and back to eating.”
Dr. John McFarland has spent his professional life trying to improve access to dental care for the underserved. He has been dental director of the Salud Family Health Centers for four decades. The Commerce City clinic is named in his honor.
A month shy of his 72nd birthday, McFarland sees about a dozen patients per day. He is the founder of the National Network for Oral Health Access and the Colorado Dental Health Network, and recognized nationally as a leader and expert on the safety net.
“I am optimistic that we have made some progress, but pessimistic that we have a long way to go,” he said.
“My sense is we need to develop programs that promote access to oral health care. It’s not just that you need to put more dentists and providers out there; you need systems of care like community health centers that will fund dental programs to make inroads into this access problem.
“Medicaid needs to be strengthened, CHP+ (the Child Health Plan Plus health insurance program for low-income children and pregnant women) needs to be strengthened. We have to get reimbursement rates at a somewhat higher level to incentivize more providers to participate.”
Braun said she’s an optimist.
“It’s not a short road, it’s a long road and it’s going to take all of our efforts teaming together as medical and dental providers to try to tackle the problem. If state policy can support care for kids and pregnant moms, there is hope to prevent this disease. It’s going to take this joint effort to get there and we have to be patient with it.
Sasha Dillavou contributed to this story.